Tracie Wallace, LPC

Primary specialty

Professional CounselorTaxonomy code 101YP2500X

License

2012029763 Issued in MO

Practice address

1023 Executive Parkway Dr Ste 10
Saint Louis, MO 63141-6323

Phone

(314) 469-5522

Fax

(314) 469-5504

NPI assigned

May 7, 2015

Sex

Female

Sole proprietor

Yes

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Opted out of Medicare

Yes, effective Mar 25, 2026 through Mar 25, 2028

Medicare enrollment (NPD)

Not enrolled

State licenses

Practice roles

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

• Crossroads Christian Counseling

  • Professional Counselor
  • Saint Louis, MO
  • NPI 1477728400
  NPD (past)

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1430956800000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1430956800000",
    "number": "1306224613",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1023 EXECUTIVE PARKWAY DR STE 10",
            "city": "SAINT LOUIS",
            "state": "MO",
            "postal_code": "631416323",
            "telephone_number": "314-469-5522",
            "fax_number": "314-469-5504"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1023 EXECUTIVE PARKWAY DR STE 10",
            "city": "SAINT LOUIS",
            "state": "MO",
            "postal_code": "631416323",
            "telephone_number": "314-469-5522",
            "fax_number": "314-469-5504"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "WALLACE",
        "first_name": "TRACIE",
        "credential": "LPC",
        "sole_proprietor": "YES",
        "sex": "F",
        "enumeration_date": "2015-05-07",
        "last_updated": "2015-05-07",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "101YP2500X",
            "taxonomy_group": "",
            "desc": "Counselor, Professional",
            "state": "MO",
            "license": "2012029763",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Lisa Wallace, DO
• Maxwell Wallace, M.D.
• Michael Patrick Wallace, DMD
• Paige Wallace
• Pamela Yvonne Wallace, REGISTER NURSE
• William Gregoy Wallace, RPH
• Marc Allan Wallach, DDS
• Samala Wallack, LPC
• Tanner Wallen, DO
• Karl Christian Wallenkampf, MD

• Professional Counselor in Saint Louis, MO
• Providers in Saint Louis, MO by specialty
• Professional Counselor in Missouri

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on May 7, 2015; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Opt Out Affidavits.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.